Perhaps one of the more sidestepped topics when it comes to doctor’s visits is a discussion of sexual health. Beyond STI risk assessment, it is not a topic that is broached, even if a doctor reports feeling comfortable asking about it. For instance, in a study of 416 physicians across 4 specialties respondents reported they were comfortable with talking about sexual history, but 76% of physicians reported only asking if they felt it was relevant to a chief complaint.1 Meanwhile, patients report wishing their doctor would inquire more deeply or seriously about their sexual history as part of routine care.2 While this issue has been discussed regularly in medical circles, its research remains, understandably, solely in the realm of diagnosis and prevention of illness. What is often lacking is a discussion of the value of sexual activity, particularly concerning elder populations. Regardless of age, sexual satisfaction is an important part of the foundations of health and is associated with improvements in cardiovascular health4, mental health5, and overall life enjoyment levels.6 While sexual activity levels typically decrease with age after 656 large proportions of older adults still do desire sexual contact.7 However, sexual dysfunction and dissatisfaction are often not brought up with geriatric populations, and the conventional tools to treat these concerns are limited. Fortunately, herbs have been used since antiquity to address this exact issue through their ability to promote healthy libido, improve energy, and promote blood flow, among many other actions that will ultimately lead to improved sexual health in those of advanced age.
Ashwagandha is perhaps one of the most famously known herbs for supporting sexual function in both men and women. While there is data to reflect that Ashwagandha supports testosterone levels in men, there is mixed data in women. However, in post-menopausal women testosterone becomes an important hormone in the regulation of female libido.11 One pilot study of 50 subjects found ashwagandha extract improved sexual function including levels of arousal as well as vaginal lubrication with 300mg twice daily of ashwagandha given over an 8-week period.12 These results demonstrate that ashwagandha certainly can play a supportive role for all genders seeking support for their sexual function. Similarly, a study of men aged 40 to 70 years old who were overweight and reported low energy, libido, and self-esteem took 600mg of ashwagandha extract daily and reported subjective improvements in mood, energy, and libido and objectively found improvements in testosterone as well as salivary DHEA-S. Dehydroepiandrosterone sulfate, an ester of DHEA which may act as a prohormone, but significantly acts as a neurotrophin, that is, a class of proteins that relate to the longevity of neural tissues.14 These studies, coupled with ashwagandha’s long-standing traditional use as a vitality extender, suggest that ashwagandha may be a first-line herbal support option for those seeking to support sexual function and satisfaction.
Shatavari is a unique herb in the Ayurvedic materia medica as it was extensively used in ancient times for an array of systemic ailments and infections.15 Somehow throughout the millennia, this herb has become primarily associated with supporting the female reproductive system with some animal and human trials agreeing with this use. For instance, it offered support to the nervous system in ovariectomized rats.16 In vivo research has also found Shatavari to be used in concert with other herbs to promote healthy estrogen levels.17 In human trials, it has been found to improve muscle function in post-menopausal individuals.18
Shilajit is a pale‐brown to blackish‐brown exudate from the layers of rocks in many mountain ranges of the world including the Himalayas and Hindukush ranges of the Indian subcontinent. It is a complex mixture of organic humic substances and plant and microbial metabolites that is attributed with improving stamina, libido, mental alacrity, and improves mood specifically in geriatric individuals looking for stress relief.19 Its name, Shilajit, is translated as “conqueror of the mountains and destroyer of weakness”20 which speaks directly to its use in supporting longevity and healthy energy levels. Furthermore, it has a long history of use in promoting fertility in men. Research today shows that Shilajit does have some spermatogenic qualities to it as well.21 Similarly, human trials have also demonstrated modest improvements in muscular strength in healthy individuals.22
Saffron, the delicious spice known to be one of the most expensive in the world, has a long history of use as a supportive herb for all aspects of the mind and spirit in Ayurveda. Today, it is well recognized through human trials to support healthy mood23, memory24, and the cardiovascular system25, and may even provide some immune and joint support.26 It has also been studied for improving many of the symptoms of menopause including hot flashes.27 In short, saffron is an excellent addition to support healthy libido and sexual function later in life by supporting both the body and mind.
Tribulus terrestris has been used to support healthy sexual function in both men and women for thousands of years.28 It has long been purported that its steroidal saponin content has direct influence over sex hormones in men and women, but modern trials have not seen this in a statistically significant way.29 Nevertheless, what modern trials have managed to document in humans are the outcomes. For instance, one trial of 67 women found that 4 weeks of 7.5mg of Tribulus extract daily improved scores on the Female Sexual Function Index (FSFI).30 Another trial of 86 males found improvement as reported on their International Index of Erectile Function (IIEF) Questionnaire.31 Given this, the mechanism of Tribulus may be elusive, but the results support healthy sexual function.
When it comes to improving sexual health in an individual, there are certain foundations that must be addressed before initiating supplement and botanical protocols. For instance, polypharmacy is common in older adults and especially those with multiple conditions.8 Therefore, a proper review of all medications and supplements, along with checking for interactions, is crucial. Another important factor, especially in male sexual function, is assessing for blood sugar dysregulation and diabetes. One meta-analysis of 145 different studies found men between the ages of 49 and 67 with diabetes (both type 1 or 2) are 3.5 times more likely to have erectile dysfunction.9 Similarly, the cardiovascular system must be assessed. For instance, 35% of all hypertensive men will also have erectile dysfunction, in addition, hyperlipidemia is found in about 42% of men with erectile dysfunction.10
One of the simplest ways to improve and support healthy sexual function is to incorporate an exercise regimen. As expected, the benefits of regular exercise are far-reaching and do include improving sexual function and enjoyment as well. On average, about 150 minutes of exercise per week is recommended with a mixture of weight training, aerobic, and flexibility exercises. Yoga in particular can be useful. One study has found yoga plus aerobic exercise as a mixture leads to physical stamina improvements as well as more robust mental alacrity compared to those who do not practice yoga.35 These effects will be further improved by limiting or eliminating alcohol and tobacco products.
Like exercise, dietary interventions are far-reaching in their valuable effects on human health. In particular, antioxidant-rich foods like fruits and beans are important for supporting vascular function and thus improving cardiovascular health necessary to support sexual function. Moreover, nuts and seeds offer micronutrients such as zinc, vitamin E, and vitamin B6, as well as phenolic compounds which have been linked to improving sexual function in some individuals.36 Another trial focusing on weight loss found caloric restriction resulting in weight loss led to significant improvement in sexual function and satisfaction.37
An often overlooked key factor when looking to provide sexual health support to aging populations is to assess both the patient and their partner(s). In fact, some researchers have found that it can be unhelpful, if not detrimental, to treat the symptoms of one member of a couple, but not the other.13 The concept of “Couplepause” which focuses on when a couple faces the normal changes of aging and the influence this has on sexual function, offers a key link into the “mind body spirit” nature of sexual function and should be explored further. For instance, discussing the need to adapt sexual activity to make room for normal and natural changes can be reframed less as a set of problems but rather as an exciting time for new solutions. Moreover, adapting to more intensely intimate behaviors as a routine part of physician intimacy, such as cuddling and lying next to each other can be as fulfilling emotionally as sexual activity.34
SOLITUDE AND THE SPIRIT: THE IMPORTANCE OF CONNECTION
Not every patient of advanced age is going to be partnered with an individual and seek support in the bedroom. As a result of time, relationships end for a variety of reasons. Isolation and loneliness are well understood to be linked to declines in emotional, cognitive, and physical health.32 While both ageism and internalized ageism are common barriers for our elderly population which stop them from engaging in a larger social circle, it is of vital importance for caregivers to encourage and advance social engagement in instances where this may be lacking. Daycare centers for active aging, assisted living communities for senior citizens, peer support interventions, and psychosocial support through the contact of volunteers in person or by telephone are some of the interventions that are being explored for promoting companionship for our elders.33 Given the preestablished factor that sexuality is rarely discussed in geriatric visits, coupled with the reality that many physicians are likely also not inquiring about psychosocial support, it is germane to mention the importance of these factors. Whether to remind a patient to bring them up at their next visit or for the savvy clinician to explore the vital foundation of health that is human connection.
Sexual health is widely side-stepped in clinical encounters when it is not related to a chief complaint. Our elderly populations are at an additional loss because they are unlikely to bring the topic up if not asked. Yet, regardless of this clinician conundrum, many patients of advanced age report wishing their clinicians would talk to them about this issue, and that there is a desire for support and education. Fortunately, plants have been used for millennia to help ease and support individuals seeking to better their sex lives later in life. Moreover, assuring that the foundations of health are utilized by elderly individuals, they will be able to continue enjoying healthy sexual function and satisfaction that they control.
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